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  • Steve Hodges, M.D.

From the Bedwetting Case File: A Lesson about Enemas and Treating Constipation in Kids

A recent case from my bedwetting clinic offers a valuable lesson about enemas and the challenges of treating chronic constipation.

My patient was a 10-year-old boy who, at our first visit, had been struggling with encopresis (chronic poop accidents) and both daytime and nighttime wetting.

This is a common scenario, as encopresis and enuresis (wetting, whether daytime or nighttime) have the same cause: chronic constipation. In other words, a rectum stretched by a build-up of stool.

The enlarged rectum aggravates the bladder nerves, triggering wetting accidents. Meanwhile, the rectum loses tone, the way a stretched sock loses elasticity, as well as sensation. Since the child can’t feel the urge to poop and lacks the rectal tone to fully evacuate, poop drops out of the child’s bottom, without the child even noticing.

My 10-year-old patient and his parents were, naturally, distressed by the ongoing accidents and didn’t balk at the standard treatment I recommend for enuresis and/or encopresis: the Modified O’Regan Protocol (M.O.P.), a regimen that includes daily enemas.

They hadn’t gotten anywhere with the laxatives and bladder medications the boy had been prescribed elsewhere.

“OK, let’s do it!” the mom said. Her son agreed, with more enthusiasm than you might expect from a 5th-grader facing nightly enemas.

The family chose to start with large-volume enemas. These enemas, using a reusable enema bag filled with saline solution and a liquid stimulant, are more trouble than store-bought enemas, but they are often more effective, and this family wanted to go all out.

After a few weeks of nightly enemas, the boy’s poop accidents stopped. A month or so later, he stopped wetting during the day. There was joy in Mudville!

Still, every morning, the boy’s pull-ups were as drenched as ever.

Again, this is totally common. Bedwetting almost always takes far longer to resolve than daytime accidents, for reasons I explain in the The M.O.P. Book: Anthology Edition. You can’t expect bedwetting to diminish, let alone stop, until daytime accidents have ceased.

My standard advice for this boy’s scenario: You’re doing great — stay the course!

But this family was on a mission. Intent on doing the maximum to help her son achieve dryness, the mom asked: “What’s next? What else can we do?”

I introduced her and her son to the Peristeen pump, a pressurized anal irrigation system that is essentially a large-volume enema on steroids. Designed for people with nervous-system conditions, like spina bifida, that prevent the bowel from functioning properly, the pump works very well in the most stubbornly clogged children.

“OK, let’s do it!” the mom said. Again, her son agreed. At this point he was so excited to have clean, dry underwear all day that he was willing to do anything to achieve dryness overnight.

This is where the story veers off course.

Despite using the pump every single night for three months, the boy continued to wet the bed. The family was frustrated and baffled and questioned whether constipation was actually causing the boy’s bedwetting.

“Could it be something else?” the mom asked? “He can’t possibly still be clogged up.”

To resolve that question, I ordered an x-ray of the boy’s abdomen. The answer: yes, the boy’s rectum was still clogged. Big time.

Honestly, even I was blown away by what the film showed, and I’m almost never surprised by what I see on x-rays.

This boy’s rectum measured 7.5 centimeters in diameter, and the mass of stool wedged in his rectum measured 9 cm in length. So, basically, this kid had a poop mass larger than a tennis ball clogging his rectum.

To put this in perspective: a normal rectum measures no more than 3 cm in diameter and contains no stool at all.

(Yes, there’s always stool in the colon, but the rectum — the very end of the colon — is not designed as a storage facility. Normally, the arrival of stool in the rectum stimulates the urge to poop, and you fully evacuate. A stool pile-up in the rectum means this process has been upended.)

Now, I see 7.5-cm measurements every day in my clinic — that’s absolutely typical for a kid with encopresis and enuresis. But I would not expect such a measurement from a child who had been receiving powerful enemas every night for 3 months!

How could this kid still be clogged?

In truth, I don’t know. Some kids simply do not respond to the most aggressive constipation treatments.

But here’s an interesting corollary: Some kids actually respond better to less aggressive enemas.

I sent this boy off with a treatment variation called M.O.P.x. Instead of using a larger, more powerful enema, we’d shift gears and use liquid glycerin suppositories (LGS), basically mini-enemas, plus a daily regimen of high-dose Ex-Lax.

This variation of M.O.P., explained in the M.O.P. Anthology, has worked well for many kids who have overcome daytime accidents on large-volume enemas but can’t get over the hump with bedwetting.

Will smaller enemas work for this boy? I don’t know. I just sent the kid off a week ago, and in my experience, you can’t make any judgments until you’ve tried a regimen for 30 days. However, I’ve seen this approach succeed many times.

My points: 1.) You can’t ever assume “enema = empty” and 2.) You can’t predict what type of enema will work for any given child.

Let’s start with the first point.

Most parents in my clinic and in my private Facebook support groups report they’ve been warned by physicians that enemas — even the small varieties you buy in the store — are “too extreme,” “too invasive” and “overkill.”

Doctors typically recommend Miralax, Miralax, and more Miralax: “If you just take enough Miralax, eventually it’ll work,” they tell families.

(If Miralax alone resolved enuresis and encopresis, my clinic would be empty! In fact, Miralax often makes encopresis worse and is usually inadequate to resolve enuresis.)

Parents are left with the impression that an enema is like some kind of fire-hose-level blast that — while inevitably clearing out the rectum — will leave kids traumatized and possibly with an injured sphincter.

Reality check: As my 10-year-old patient’s case demonstrates, even the most powerful enemas on the market not only cause no physical or emotional trauma but may not even clean out a hard mass of stool!

READ: Don't Put Off Bedwetting Treatment for Your Child

READ: Tired of Waiting for Your Child to Outgrow Bedwetting?

When physicians do, grudgingly, approve of enemas, they typically caution parents against doing more than two or three, suggesting — without any evidence — that a daily enema regimen will cause dependence and electrolyte imbalance. (I discuss these and other unfounded objections at length in the Anthology.)

Fact is, some folks with neurological conditions use the Peristeen pump every day of their lives with no problem whatsoever. So, a few months of daily enemas can hardly be considered harmful.

But back to my main point: You can’t assume that the mere insertion of an enema is going to work magic. You need to find the right enema that works for your child, and that takes experimentation. The three types I most commonly use with patients:

•Phosphate enema. Labeled “saline laxative enema” (even though the active ingredient is phosphate), this is a ready-made enema available at the pharmacy or online.

•Liquid glycerin suppository. A mini-enema containing pure glycerin rather than a mix of saline solution and phosphate. Also available commercially, though you can make them yourself.

•Large-volume enema kit. You buy a reusable enema kit and mix the liquid yourself, combining saline solution with stimulants such as glycerin and/or Castile soap.

All these enemas stimulate a bowel movement quickly, usually within 10 minutes. (Some kids, especially when very clogged, can’t hold the enema for more than a minute or two, and that’s OK.)

Some kids respond better to phosphate. Others get more output from glycerin. Others do best with large-volume enemas with Castile soap. And so on.

For stubbornly constipated children, I also recommend overnight oil-retention enemas. Before bed, you insert olive oil or mineral oil using a syringe or enema bottle. The oil sits overnight, softening crusty stool. In the morning, a stimulant enema flushes out the oil and loosened stool. (This regimen, known as Double M.O.P., is explained in detail in the Anthology.)

When all this doesn’t work, I recommend the Peristeen pump, which really does work for just about every child — just not that 10-year-old boy. (I have confidence that M.O.P.x, possibly in conjunction with oil-retention enemas, will work for him.)

In M.O.P. for Teens and Tweens, my book for middle-school and high-school students with enuresis and/or encopresis, I provide a great example of how different kids — even siblings — may need radically different regimens. A mom with two teens on M.O.P., a 13-year-old boy and a 15-year-old girl, explains:

“For my son, Fleet phosphate enemas have always worked best. We tried adding mineral oil enemas, which never got much out. Neither did large-volume enemas, so we went back to phosphate. Now that he has been dry for two months, we only do the enemas on nights when he has no spontaneous bowel movement.”

As for her daughter: “Fleet phosphate enemas weren’t producing output, so we switched to liquid glycerin suppositories. For her, adding mineral oil enemas was very helpful.”

Whatever regimen you try with your child, assume that clearing out your child’s rectum will be more challenging than you expected.

As one mom in my private support group posted: “Years of poop build-up is hard to clean out. I feel like I am chipping away at a cement block with a garden hose!”

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Must-read books for kids by Steve Hodges, M.D.

• Bedwetting and Accidents Aren't Your Fault

• Jane and the Giant Poop